Making Surgery Safer:Making Surgery Safer:Surgical Infection

PreventionTeam Members:Anesthesia: W. Scott Jellish – chair, Maureen KawkaInfectious Disease: Paul O’Keefe, Chris SchrieverSurgical Services: Jeri Katsaros, Meg Kim, Peggy VorrierLabor & Delivery: Maureen DaveyQuality Resource Management: Carmen Barc, Vada Grant, Susan TuzikInfection Control: Jan Bartel, Alexander TomichCCE: Mary Altier, William Barron, LuAnn Vis, Michael Wall

Magnet Forces: 6 - Quality of Care7 - Quality Improvement13 - Interdisciplinary Relationships

Confidential: For Quality Improvement Purposes Only

Aim StatementAim StatementSurgical site infections are a major

complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics – giving the right drug at the right time – is effective in preventing infections after surgery*. Other perioperative measures – glucose control, temperature control, and appropriate hair removal – have also been proven effective in reducing infections

*Bratzler, DW, et al. Use of Antimicrobial Prophylaxis for Major Surgery: Baseline Results from the National Surgical Infection Prevention Project, Arch Surg Feb 2005; 140:174-182.

Confidential: For Quality Improvement Purposes Only

Project GoalsProject GoalsTo achieve compliance for the following measures:

– Administer antibiotics within one hour before surgical incision

– Administer the appropriate antibiotic– Stop antibiotics within 24 hours after surgery (48 hours

after cardiac surgery)– Controlled postoperative serum glucose (200mg/dl or

less) – Cardiac surgery patients– Appropriate hair removal – No razors– Immediate postoperative normothermia – Colorectal

surgery patients

These measures are publicly reported at www. hospitalcompare.hhs.gov

Confidential: For Quality Improvement Purposes Only

Solutions Implemented in Solutions Implemented in 2007/20082007/2008

Data management and results– Reviewed all outliers to identify trends; provided

follow up physician education– Created system to forward physician-specific reports

to the Chairs, individual physicians, and the Chief of Staff

– Forwarded results externally:• Illinois Report Card Act – beginning July 07 cases• The Joint Commission – beginning January 08

cases• Hospital Compare - Ongoing

Confidential: For Quality Improvement Purposes Only

Solutions Implemented in Solutions Implemented in 2007/20082007/2008Antibiotic orders

– Revised order sets to address MRSA risk – Revised Endocarditis Prophylaxis Guidelines*

Hair removal– Removed razors from OR, Pre-op holding; limiting

access to SRP – Educated procedure areas on appropriate hair

removal– Physician education to eliminate learned phrase

“shaved and prepped” when a clipper was used for hair removal

Normothermia– Tested warming blankets and thermal caps

*Wilson et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. Circulation 2007; 116:1736.Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients who received prophylactic antibiotics within 60 minutes prior to surgical incision / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Vancomycin and fluoroquinolones timeframe is extended to 120 minutes prior to incision.

Data source: LUMC medical records abstracted by RNs.

Analysis: Ninety-six percent of LUMC patients receive prophylactic antibiotics within the recommended timeframe prior to surgical incision.

Per

cen

t

Surgical patients receiving prophylactic antibioticswithin one hour prior to surgical incision

UCL = 106.3

Mean = 96%LCL = 86.1

Jan 2

006

(n=3

8)

Feb 2

006

(n=3

7)

Mar

200

6 (n

=34)

Apr 200

6 (n

=31)

May

200

6 (n

=37)

Jun 2

006

(n=3

5)

Jul 2

006

(n=2

5)

Aug 200

6 (n

=26)

Sep 2

006

(n=2

2)

Oct 2

006

(n=3

3)

Nov 20

06 (n

=35)

Dec 2

006

(n=3

4)

Jan 2

007

(n=2

9)

Feb 2

007

(n=3

4)

Mar

200

7 (n

=35)

Apr 200

7 (n

=32)

May

200

7 (n

=33)

Jun 2

007

(n=2

5)

Jul 2

007

(n=3

0)

Aug 200

7 (n

=36)

Sep 2

007

(n=3

4)

Oct 2

007

(n=3

2)

Nov 20

07 (n

=35)

Dec 2

007

(n=3

4)

Jan 2

008

(n=3

4)

Feb 2

008

(n=3

0)0

20

40

60

80

100

Month (number of patients)

Antibiotics added to ‘time out’ process

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients receiving prophylactic antibiotics consistent with current guidelines / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Analysis: Ninety-five percent of LUMC patients now receive prophylactic antibiotics consistent with current guidelines. Additional initiatives were implemented in February and March 2007 to ensure that all surgical patients receive antibiotics consistent with current guidelines.

Per

cen

t

Surgical patients receiving prophylactic antibioticsconsistent with current guidelines

UCL = 106.1

Mean = 91%

LCL = 76.7

Jan 2

006

(n=3

8)

Feb 2

006

(n=3

6)

Mar

200

6 (n

=34)

Apr 200

6 (n

=34)

May

200

6 (n

=39)

Jun 2

006

(n=3

7)

Jul 2

006

(n=2

5)

Aug 200

6 (n

=26)

Sep 2

006

(n=2

3)

Oct 2

006

(n=3

5)

Nov 20

06 (n

=35)

Dec 2

006

(n=3

5)

Jan 2

007

(n=3

1)

Feb 2

007

(n=3

4)

Mar

200

7 (n

=36)

Apr 200

7 (n

=32)

May

200

7 (n

=33)

Jun 2

007

(n=2

5)

Jul 2

007

(n=3

2)

Aug 200

7 (n

=36)

Sep 2

007

(n=3

4)

Oct 2

007

(n=3

2)

Nov 20

07 (n

=33)

Dec 2

007

(n=3

2)

Jan 2

008

(n=3

4)

Feb 2

008

(n=3

0)0

20

40

60

80

100

Month (number of patients)

Order set modification to assist in prescribing within guidelines

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. CABG and other cardiac surgeries are allowed 48 hours.

Data source: LUMC medical records abstracted by RNs.

Analysis: Performance is consistent at 91%.

Per

cen

t

Surgical patients with prophylactic antibioticsdiscontinued within the recommended timeframe

UCL = 106.3

Mean = 91%LCL = 75.7

Jan 2

006

(n=3

7)

Feb 2

006

(n=3

3)

Mar

200

6 (n

=33)

Apr 200

6 (n

=31)

May

200

6 (n

=36)

Jun 2

006

(n=3

6)

Jul 2

006

(n=2

5)

Aug 200

6 (n

=26)

Sep 2

006

(n=2

1)

Oct 2

006

(n=3

3)

Nov 20

06 (n

=35)

Dec 2

006

(n=3

4)

Jan 2

007

(n=2

8)

Feb 2

007

(n=3

3)

Mar

200

7 (n

=34)

Apr 200

7 (n

=32)

May

200

7 (n

=33)

Jun 2

007

(n=2

4)

Jul 2

007

(n=3

0)

Aug 200

7 (n

=35)

Sep 2

007

(n=3

4)

Oct 2

007

(n=3

0)

Nov 20

07 (n

=33)

Dec 2

007

(n=3

2)

Jan 2

008

(n=3

4)

Feb 2

008

(n=2

9)0

20

40

60

80

100

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Percent of cardiac surgery patients with controlled 6AM post-operative glucose. Control is defined as serum glucose reading of 200mg/dL or less on both post-operative day 1 and day 2. Results show cardiac surgery patients with the presence of post-operative day 1 and day 2 glucose measurements, readings closest to 6AM were selected for inclusion.

Data Source: LUMC medical records abstracted by RNs.

Analysis: 6AM postoperative glucose control on both postoperative days 1 and 2 has been consistent at 90% for the past 18 months.

Per

cen

t

Controlled Postoperative Serum Glucose - Cardiac Surgery Patients

Month (number of patients)

UCL = 117.1

Mean = 90%

LCL = 63.7

Jul 2

006

(n=8

)

Aug 200

6 (n

=7)

Sep 2

006

(n=5

)

Oct 2

006

(n=1

2)

Nov 20

06 (n

=10)

Dec 2

006

(n=1

3)

Jan 2

007

(n=1

4)

Feb 2

007

(n=1

3)

Mar

200

7 (n

=12)

Apr 200

7 (n

=11)

May

200

7 (n

=13)

Jun 2

007

(n=1

1)

Jul 2

007

(n=1

2)

Aug 200

7 (n

=11)

Sep 2

007

(n=1

2)

Oct 2

007

(n=1

1)

Nov 20

07 (n

=12)

Dec 2

007

(n=1

2)

Jan 2

008

(n=1

1)

Feb 2

008

(n=9

)0

20

40

60

80

100

120

Confidential: For Quality Improvement Purposes Only

Definition: Number of Surgical cases abstracted without the use of razors for hair removal / Number of Surgical Cases Sampled. Appropriate hair removal includes: use of clippers, use of depilatory, or no hair removal.

Data source: LUMC medical records abstracted by RNs.

Analysis: The rate of appropriate hair removal decreased in late 2007 due to a change in the measure definition. The definition now assumes a patient was shaved with a razor, if physician documentation states ‘shaved’ within the chart. Education for surgeons in December 2007 has shown improvement back to baseline levels.

Month (number of patients)

UCL = 103.8

Mean = 94%LCL = 84.8

Jul 2

006

(n=4

0)

Aug 200

6 (n

=40)

Sep 2

006

(n=4

0)

Oct 2

006

(n=5

8)

Nov 20

06 (n

=58)

Dec 2

006

(n=5

7)

Jan 2

007

(n=5

7)

Feb 2

007

(n=5

7)

Mar

200

7 (n

=57)

Apr 200

7 (n

=53)

May

200

7 (n

=55)

Jun 2

007

(n=5

7)

Jul 2

007

(n=5

4)

Aug 200

7 (n

=58)

Sep 2

007

(n=5

6)

Oct 2

007

(n=5

6)

Nov 20

07 (n

=56)

Dec 2

007

(n=5

7)

Jan 2

008

(n=5

1)

Feb 2

008

(n=5

6)0

20

40

60

80

100

Per

cen

t

Surgical Patients with Appropriate Hair Removal - (Not Razors)

Confidential: For Quality Improvement Purposes Only

Definition: Number of colorectal surgery cases with normal body temperature (normothermia) immediately after surgery/ Patient undergoing colorectal surgery cases. Normothermia is defined with as a temperature of 96.8°F – 100.4°F.

Data source: LUMC medical records abstracted by RNs.

Analysis: The rate of immediate post-operative normothermia in colorectal surgeries is 65%.

Immediate Postoperative Normothermia - Colorectal Surgeries

Month (number of patients)

UCL = 134.07

Mean = 65%

LCL = 0.00

Jul 2

006

(n=4

)

Aug 200

6 (n

=5)

Sep 2

006

(n=4

)

Oct 2

006

(n=5

)

Nov 20

06 (n

=4)

Dec 2

006

(n=4

)

Jan 2

007

(n=2

)

Feb 2

007

(n=5

)

Mar

200

7 (n

=5)

Apr 200

7 (n

=4)

May

200

7 (n

=5)

Jun 2

007

(n=3

)

Jul 2

007

(n=3

)

Aug 200

7 (n

=6)

Sep 2

007

(n=3

)

Oct 2

007

(n=4

)

Nov 20

07 (n

=5)

Dec 2

007

(n=4

)

Jan 2

008

(n=5

)

Feb 2

008

(n=6

)0

20

40

60

80

100

120

140

160

Per

cen

t

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients receiving 100% of indicated antibiotic prophylaxis, glucose control, hair removal, temperature control, beta-blocker continuation, and venous thromboembolism therapy / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Analysis: Seventy-eight percent of selected surgical patients are receiving all indicated care to prevent surgical infections. This performance is better than 92% of UHC academic hospitals.

Per

cen

t

Surgical Care Improvement Project Composite PerformanceUCL = 94.9

Mean = 77%

LCL = 59.1

Loyola Goal = 90%

Jan 2

006

(n=3

8)

Feb 2

006

(n=3

7)

Mar

200

6 (n

=34)

Apr 200

6 (n

=34)

May

200

6 (n

=39)

Jun 2

006

(n=3

7)

Jul 2

006

(n=4

0)

Aug 200

6 (n

=40)

Sep 2

006

(n=4

0)

Oct 2

006

(n=5

8)

Nov 20

06 (n

=58)

Dec 2

006

(n=5

7)

Jan 2

007

(n=5

7)

Feb 2

007

(n=5

8)

Mar

200

7 (n

=57)

Apr 200

7 (n

=54)

May

200

7 (n

=55)

Jun 2

007

(n=5

7)

Jul 2

007

(n=5

4)

Aug 200

7 (n

=58)

Sep 2

007

(n=5

6)

Oct 2

007

(n=5

6)

Nov 20

07 (n

=56)

Dec 2

007

(n=5

7)

Jan 2

008

(n=5

1)

Feb 2

008

(n=5

6)0

20

40

60

80

100

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Next StepsNext Steps• Revise orders to address MRSA screen

positive results• Identify improvement opportunities for

hair removal and normothermia measures• Infection Control Committee to

investigate surgical site infection benchmarking opportunities

• Incorporate related Hospital Outpatient Department Quality Measures into project – Antibiotic measures for ASC, EP Lab, L&D

Confidential: For Quality Improvement Purposes Only